The ACA: Access, Choice and Anticipation

Reflecting on the decision by the U.S. Supreme Court to uphold the Affordable Care Act (ACA), it is clear that there’s now a law in place as significant as the creation of Medicare and Medicaid in 1965. The ACA or “Obamacare” is not just an expansion of healthcare to the uninsured but a plan to repurpose our delivery system to lower costs and supply better quality care.

Getting that law in place meant that President Obama and congressional leaders had to stick their necks out to create a system of health care that recognizes that the right to healthcare is a matter of human dignity.

But getting insurance companies and the pharmaceutical industry to support reform meant making concessions that liberals —and I am one— didn’t want, such as the elimination of the “public option.” That option would have created a subsidized federal benefit corporation that would have competed with private health insurance companies.

With an estimated 50 million people in the United States uninsured, compromises were necessary.

Under Obamacare, insurers can no longer cherry-pick from among those without preexisting conditions. In eliminating bad practices, the law treats insurers as regulated utilities. The benefits since the ACA became law in 2010 include guaranteeing coverage for millions of children with serious chronic illnesses and other preexisting conditions.

The recession that began in 2007 brought the need for such reform into sharp relief. That recession exacerbated the financial plight of the uninsured, particularly those who lost coverage when they lost their jobs. Even those with insurance policies sometimes learned they weren’t fully covered, especially when confronted with catastrophic health events. Faced with limits on the amount of insurance paid over a lifetime, many “insured” have faced bankruptcy as they try to pay for uncovered care.

But under the ACA, change is already afoot. Managed-care companies, like other insurers, are now required to spend 80 percent of their revenue on paying for healthcare services and no more than 20 percent on administration, marketing and profits. Patients are now entitled to refunds if insurers fail to meet those percentages—and some patients and employers have already received checks.

For those with disabilities, the law supports, through Medicaid reform, the delivery of long-term care in the least-restricted settings, making it possible for people to move out of institutions. Meanwhile, the expansion of Medicaid to individuals below 133 percent of the official poverty line will also extend insurance coverage. In 2014, insurers will no longer be able to refuse coverage based on preexisting conditions.

At the state level, the impact of different policies also sheds light on why Medicaid matters.  With some states saying yes to expansion and others saying no, there is an excellent opportunity to see what health gains or losses take place in light of the ACA.

This is what can be called a natural experiment, similar to following through time patients who were added to Medicaid via lottery as in Oregon, versus those who were not but have been checked on periodically to determine their health status, use of services and out-of-pocket expenditures.

Though the opponents of Obamacare will continue to fight it, this historic decision means long-overdue change. More people will be covered and healthcare delivery systems will improve. An increasing number of primary-care-driven health homes and accountable-care organizations could lead to reductions in the cost of care with fewer people rehospitalized unnecessarily or seeking help in emergency departments.

The Affordable Care Act recognizes the human side of health care. While I still prefer a fair and balanced single-payer system, we need to give the ACA a chance to see how it works.